Forum (letter, comments)

From Shakespeare to Star Trek and beyond: a Medline search for literary and other allusions in biomedical titles.Goodman NW
BMJ. 2005 Dec 24;331(7531):1540-2.

OBJECTIVES: To document biomedical paper titles containing literary and other allusions. DESIGN: Retrospective survey. SETTING: Medline (1951 to mid-2005) through Dialog Datastar. MAIN OUTCOME MEASURE: Allusions to Shakespeare, Hans Christian Andersen, proverbs, the Bible, Lewis Carroll, and movie titles, corrected and scaled for five year periods 1950-4 to 2000-4. RESULTS: More than 1400 Shakespearean allusions exist, a third of them to "What's in a name" and another third to Hamlet-mostly to "To be or not to be." The trend of increasing use of allusive titles, identified from Shakespeare and Andersen, is paralleled by allusions to Carroll and proverbs; the trend of biblical allusions is also upward but is more erratic. Trends for newer allusions are also upwards, including the previously surveyed "paradigm shift." Allusive titles are likely to be to editorial or comment rather than to original research. CONCLUSIONS: The similar trends are presumably a mark of a particular learnt author behaviour. Newer allusions may be becoming more popular than older ones. Allusive titles can be unhelpful to reviewers and researchers, and many are now cliches. Whether they attract readers or citations is unknown, but better ways of gaining attention exist.

Judging a book by its cover: descriptive survey of patients' preferences for doctors' appearance and mode of address.
Lill MM, Wilkinson TJ
BMJ. 2005 Dec 24;331(7531):1524-7.

OBJECTIVE: To document patients' preferred dress styles of their doctors and modes of address. DESIGN: Descriptive survey. SETTING: Inpatients and outpatients at a tertiary level hospital, New Zealand. PARTICIPANTS: 202 inpatients and 249 outpatients, mean age 55.9 (SD 19.3) years. MAIN OUTCOME MEASURES: Ranking of patients' opinions of photographs showing doctors wearing different dress styles. A five point Likert scale was used to measure patient comfort with particular items of appearance. RESULTS: Patients preferred doctors to wear semiformal attire, but the addition of a smiling face was even better. The next most preferred styles were semiformal without a smile, followed by white coat, formal suit, jeans, and casual dress. Patients were more comfortable with conservative items of clothing, such as long sleeves, covered shoes, and dress trousers or skirts than with less conservative items such as facial piercing, short tops, and earrings on men. Many less conservative items such as jeans were still acceptable to most patients. Most patients preferred to be called by their first name, to be introduced to a doctor by full name and title, and to see the doctor's name badge worn at the breast pocket. Older patients had more conservative preferences. CONCLUSIONS: Patients prefer doctors to wear semiformal dress and are most comfortable with conservative items; many less conservative items were, however, acceptable. A smile made a big difference.

The U.S. health care system is transforming. It must. Patient-centered care (PCC) is a core quality that the system should include. This article presents the highlights of a project on the future of PCC created for the Picker Institute. As an example of futures work, this project developed four images or stories of what might happen, as well as a vision and audacious goals for what should happen to PCC. The first and most likely scenario is an increase in patient-centeredness as a function of current trends. However, in the second scenario, health care could become even more stressed and leave PCC behind as it seeks to lower cost without focusing on quality. The third scenario envisions more excellent systems that integrate PCC seamlessly into their work. The fourth scenario sees collaboration and shared responsibility, in association with advanced information tools, thereby enabling PCC to contribute to preventing illness and lowering health care costs. The scenarios indicate that the patient-centeredness of health care could improve slightly, stall, or advance significantly. The PCC Vision calls for each of us to be in charge of our health, and to get the care we need (not less and not more) in timely, effective, and personal ways consistent with our values. The audacious goals set an agenda with priorities from the PCC community. These include shared decision making by consumers, ensuring health care professionals are trained in supporting active patients, anticipating health and long-term care needs for individuals, adopting the Institute of Medicine's (IOM) simple rules for health care, and making the patient perspective a priority in policy and planning. Each of us and our organizations are confronted with the challenge of this vision and audacious goals. Health care professionals and provider systems, whether conventional or alternative in nature, face these issues. While complementary and alternative medicine (CAM) providers often get higher marks.

In 1995, federal regulations required all academic medical centers to implement policies to manage individual financial conflict of interest. At the Mayo Clinic, all staff are salaried, and all medically related intellectual property from the staff belongs to the clinic. Hence, it was necessary to develop a policy for institutional conflict of interest to complement the policy for individual conflicts of interest. This article addresses the principles and process that led to the development of the Mayo Clinic's policies that guide the management of conflict of interest of individuals and of the institution. Empowered by the Bayh-Dole Act, the Mayo Clinic participates in technology transfer through its entity Mayo Medical Ventures. Individual conflicts of interest arising from such technology transfer are associated with Institutional conflicts because all individual intellectual property belongs to the institution, per clinic policy. This policy addresses conflicts of interest that arise in research, leadership, clinical practice, investments, and purchasing. Associated with the statutory annual disclosure on personal consulting and other relationships with Industry, which are guided by federal regulations, all research protocols or grant applications require financial disclosure on initial submission and in annual progress reports. The clinic's Conflict of Interest Review Board was established to review each disclosure and recommend management of individual and institutional conflicts of interest according to policy.

Does anyone know who we are other than us?
Lucente V
Int Urogynecol J Pelvic Floor Dysfunct 2005 Oct 12;.

Unwanted foreign doctors: what is not being said about the brain drain.
Shafqat S, Zaidi AK
J R Soc Med 2005 Nov;98(11):492-3.

Brain drain is defined as the migration of health personnel in search of the better standard of living and quality of life, higher salaries, access to advanced technology and more stable political conditions in different places worldwide. This migration of health professionals for better opportunities, both within countries and across international borders, is of growing concern worldwide because of its impact on health systems in developing countries. Why do talented people leave their countries and go abroad? What are the consequences of such migrations especially on the educational sector? What policies can be adopted to stem such movements from developing countries to developed countries? This article seeks to raise questions, identify key issues and provide solutions which would enable immigrant health professionals to share their knowledge, skills and innovative capacities and thereby enhancing the economic development of their countries.

PURPOSE OF REVIEW: The National Health Service Litigation Authority has issued a warning about the process of asking a patient for their consent prior to a medical procedure. This warning was issued in the light of the case of Chester v. Afshar. For the first time in English law the courts have appeared to state that failure to give a patient adequate information about a procedure is negligent per se. This article briefly examines the history of consent since the famous case of Bolam and reviews the recent legal commentary on the case of Chester. It will also consider a proposed solution to the question 'What is adequate information?' RECENT FINDINGS: The medicolegal literature traces the change in the legal test used to determine whether a patient has been adequately informed. It charts the evolution of a 'prudent patient' test and suggests ways in which medical practitioners might adequately fulfil their duty to inform patients properly. SUMMARY: Since the case of Chester v. Afshar it has become harder for a doctor to escape a charge of negligence if they have given inadequate information at the time of asking a patient for their consent to undergo a medical procedure. It is in everyone's interests - doctor and patient - to make the process of consent transparent and to an agreed national standard.

In the past, the process of developing the young academic surgeon was arguably less strategic, one that was often not deliberately managed and monitored, leading in some cases to academic drift and disillusionment. Once upon a time it was assumed that greatness was genetic and that the next triple threat would emerge when a pre-programmed set of genes was turned on. Today, as the complexities and vicissitudes of our work increase, it is practically impossible for even the most gifted young person to be successful without careful attention to career development. Faculty development must be deliberate and strategic--every junior faculty member is unique and will require a customized career development plan that is well thought out, linked to measurable goals, monitored routinely and buttressed by effective mentoring. This approach will require time and commitment--precious commodities that are in short supply as the demands on our time are only escalating. By recruiting the right people (those who fit with the organization's values and goals) and providing the right environment, we can optimize the growth and satisfaction of our young faculty and, in so doing, create departments that are leaders in carrying out our missions of research, education and patient care. We cannot afford to have our young people fail--it is simply too costly, both from a financial and a human perspective.

Statistical Power and Estimation of the Number of Required Subjects for a Study Based on the t-Test: A Surgeon's Primer(1).
Livingston EH, Cassidy L
J Surg Res 2005 Oct;128(2):207-17.

The underlying concepts for calculating the power of a statistical test elude most investigators. Understanding them helps to know how the various factors contributing to statistical power factor into study design when calculating the required number of subjects to enter into a study. Most journals and funding agencies now require a justification for the number of subjects enrolled into a study and investigators must present the principals of powers calculations used to justify these numbers. For these reasons, knowing how statistical power is determined is essential for researchers in the modern era. The number of subjects required for study entry, depends on the following four concepts: 1) The magnitude of the hypothesized effect (i.e., how far apart the two sample means are expected to differ by); 2) the underlying variability of the outcomes measured (standard deviation); 3) the level of significance desired (e.g., alpha = 0.05); 4) the amount of power desired (typically 0.8). If the sample standard deviations are small or the means are expected to be very different then smaller numbers of subjects are required to ensure avoidance of type 1 and 2 errors. This review provides the derivation of the sample size equation for continuous variables when the statistical analysis will be the Student's t-test. We also provide graphical illustrations of how and why these equations are derived.

BACKGROUND: Infection is the major problem to treat the wound. Antibiotic resistance by the pathogenic microorganism renders drug ineffective and calls for improved designing and development of new drugs. New approach has been developed to isolate active components from botanicals. Our aim was to investigate the potential of Cassia fistula to treat the infected wound on albino rat model. MATERIAL AND METHODS: The alcohol extract of C. fistula leaves was analyzed for antibacterial effect against Staphylococcus aureus ATCC 29213 and Pseudomonas aeruginosa ATCC 27853. Formulated ointment was topically applied on the infected wound. Wound reduction rate, histological analysis, biochemical analysis, and gelatin zymography were obtained to assess the healing pattern. RESULTS: C. fistula treated rats showed, better wound closure, improved tissue regeneration at the wound site, and supporting histopathological parameters pertaining to wound healing. Biochemical analysis and matrix metalloproteinases expression correlated well with the results thus confirming efficacy of C. fistula in the treatment of the infected wound. CONCLUSION: Along with the other activities such as antitumor, antioxidant, hypoglycemic, hepatoprotective, antibacterial, hypocholesterolaemic, and antidiabetic activity, the healing potential of C. fistula provides a scientific rationale for the traditional use of this plant in the management of infected dermal wound and can be further investigated as a substitute to treat infected wounds without using synthetic antibiotics.

Appropriate statistical analyses are an integral part of surgical research. The purpose of this work is to assist surgeons and clinicians with the interpretation of statistics by providing a general understanding of the basic concepts that lead to choosing an appropriate statistical test for common study designs. It is extremely important to understand the nature of the data before embarking on a statistical analysis. A researcher must design an appropriate study around the research hypothesis. Initially, data should be inspected using frequency distributions and graphical techniques. If the data are continuous, the normality of the distribution must be assessed. In addition, the data must be defined as independent or dependent. For normally distributed and independent samples, a two-sample t test is appropriate. A paired t test should be used for dependent data. The nonparametric counterpart to the t test is the Mann-Whitney U and the paired counterpart is the Wilcoxon signed rank. For binary data, contingency table methods such as a chi(2) test apply unless the expected value is < 5; then, use the Fisher's exact test. The McNemar test applies to paired binary data. Correlation coefficients assess the association between two continuous distributions. Linear regression assesses trend. Multiple regression analysis is appropriate for multivariate analyses with a continuous outcome variable. Logistic regression methods would apply for binary outcomes. The quality of the analysis and subsequent results of any research project depend on an appropriate study design, data collection, and analysis to make meaningful conclusions.

The nature of surgical error A cautionary tale and a call to reason.
Satava RM
Surg Endosc 2005 Jul 21;

Errors and "patient safety" have taken on monumental importance for surgery. Like all things new, there is an initial over-reaction before a return to a balanced perspective. The current response to the global interest in error has been to seize on the latest reports that are focusing on the "systemic nature" of errors, which is also being referred to as "the new look." There has been an unintentional ignoring of the actual error, referred to as the coface error, that the surgeon commits. It is time to put the approach to errors into perspective and redefine errors within the context of the surgical community, which can result in a balance of the surgeon's position in regard to systemic and personal responsibility.

Reducing the number of medical errors significantly is the challenge for the coming decade. In medicine and in surgery, in particular, errors are traditionally treated as being committed by individuals. To reduce human errors, two approaches can be used: the person approach and the systems approach. In the systems approach, the operator is not blamed, but the system is analyzed in order to find the causes of errors. Furthermore, defenses are built into the system so that errors will not result in an adverse outcome anymore. This article aims to provide insight into the systems approach.

Technical operative errors cause surgical operative morbidity and adversely affect the clinical outcome of patients. Surgical proficiency thus underpins good and safe practice. In this context, standardization of endoscopic surgical operations and their execution are essential for the procurement and maintenance of quality assurance in endoscopic surgical practice. There is no clash between individual- (surgical proficiency) and system-based defense systems in the prevention of surgical errors - both underpin safe surgical practice. Although more human factors and surgical research are needed, it is possible to formulate and adopt a surgical error reduction system for endoscopic operations based on standardization of operations, surgical operative proficiency, and human reliability assessment and its related clinical counterpart, observational clinical human reliability assessment.

Teaching is not a top-down phenomenon. Teaching occurs everywhere in the organization--vertically, horizontally, and diagonally. Leaders are valued for their ability to forge relationships with very diverse groups and individuals and build partnerships that are truly mutually beneficial for all. The best leaders have dirty shoulders because they are continually lifting others up.

To encourage high-quality patient care guided by the best evidence, many medical schools and residencies are teaching techniques for critically evaluating the medical literature. While a large step forward, these skills of evidence-based medicine are necessary but not sufficient for the practice of contemporary medicine. Incorporating the best evidence into the real world of busy clinical practice requires the applied science of information management. Clinicians must learn the techniques and skills to focus on finding, evaluating, and using information at the point of care. This information must be both relevant to themselves and their patients as well as being valid. The authors discuss the need to teach the applied science of information management along with, or perhaps even instead of, teaching the basic science of evidence-based medicine. All students, residents, and practicing physicians need three skills to practice the best medicine: the ability to select foraging-"keeping up"-tools that filter information for relevance and validity, the skill to select and use a hunting-"just in time"-information tool that presents prefiltered information easily and in a quickly accessible form at the point of care, and the ability to make decisions by combining the best patient-oriented evidence with patient-centered care, placing the evidence in perspective with the needs and desires of the patient. This teaching of information management skills will prepare students and residents for a practice of medicine that requires lifelong learning.
Imperatives. Aronson MP. Am J Obstet Gynecol 2005 May;192(5):1483-7.

OBJECTIVE: This study searches for association between the subject of medical students' required research projects and subsequent choices of residency, focusing specifically on women's health fields. STUDY DESIGN: Students at our school graduating between 1997 and 2004 (n = 535) were required to undertake a research project beginning in the preclinical years. The subject of their required research project was related to their subsequent choice of residency. RESULTS: Ninety-nine of the 535 projects (18.5%) were women's health related. Although overall there was no significant relationship between the research project and residency choice, students who completed a women's health care project were nearly twice (1.8, 95% CI, 1.4-2.3) as likely to enter a women's health (obstetrics and gynecology or family medicine) residency than those who did not. CONCLUSION: An association exists between student participation in women's health research beginning during preclinical years and the subsequent choice of a women's health residency.

BACKGROUND: Basic laparoscopic skills are initially best taught and practiced in an inanimate setting. Various devices are used to aid in this education of laparoscopic skills. These devices range from simple box trainers to sophisticated virtual reality trainers. This investigation tested the hypothesis that participants would prefer one trainer to another trainer. METHODS: Preclinical medical students volunteered for this study. All underwent a porcine laboratory. The students were then divided into 3 groups by method of training: group A-a virtual reality trainer (MIST-VR), group B-an inanimate box trainer (LTS 2000), and group C-both trainers. Each group participated in 10 laboratories with the assigned trainer(s). After completion of the laboratories, all students underwent a similar porcine laboratory. During this laboratory, opinions of each trainer and specific tasks were ascertained from each student. RESULTS: No statistical difference was seen between groups A and B when asked if their specific trainer helped their skills, was realistic, helped in the animal laboratory, and was interesting. When group C was asked the same questions about each trainer, no statistical difference was seen except that 47% thought the MIST-VR was not realistic as opposed to 0% who thought the LTS 2000 was not realistic (P <.003). The level of difficulty of each task correlated with how much the specific task helped in development of skills for both trainers (P <.0001). In group C, 89% of the participants thought the LTS 2000 helped more that the MIST-VR and 56% thought the LTS 2000 was more interesting than the MIST-VR. In addition, 83% of students in group C chose LTS 2000 when asked to pick only one trainer. CONCLUSIONS: While virtual reality trainers may have some advantages, most participants feel that inanimate box trainers help more, are more interesting, and should be chosen over virtual reality trainers if only one trainer is allowed. Further studies need to investigate if the opinions affect participants' utilization of these trainers.

BACKGROUND: There is a need for reliable and valid objective methods of technical skills in surgery. Six-bench surgical top stations have been combined to assess basic surgical trainees (BSTs) objectively. The current study examines its reliability and validity across repeat sittings. METHODS: Eleven surgical trainees (6 senior BSTs and 5 higher surgical trainees [HSTs]) undertook 5 sittings of the 6-station assessment designed to be completed within 90 minutes. The 6 stations consisted of knot tying, suturing, closure of enterotomy, excision of sebaceous cyst, laparoscopic task, and instrument examination. Methods of analysis employed were motion analysis, observation with criteria, and inbuilt simulation metrics. RESULTS: On analysis 3 knot tying and suturing stations exhibited significant differences in either time or movement; any difference was over by the second run. The intertest reliabilities were .66, .74, .55, .51, and .65 for the 5 runs. The intratest reliability across repeated sittings varied from .56 to .96. The inter-rater reliability for video assessment varied from .77 to .94. CONCLUSION: The assessment is reliable and valid across repeated sittings. Its use in assessment of basic technical skills needs to be encouraged.

BACKGROUND: This study descriptively analyzes characteristics of general surgery residency and practice and their influence on student interest in surgical careers. METHODS: Fourth-year medical students were invited to complete an Internet-based survey. A 5-point Likert scale described characteristics of general surgery residency and practice influencing medical student specialty selection. The same characteristics of nonsurgical careers were evaluated for students entering other specialties. RESULTS: A convenience sample of 408 students from 16 medical schools completed the survey. All respondents viewed lifestyles of surgical residents and attending surgeons as negative influences on specialty selection. Workload during surgical residency negatively influenced all respondents' interest in a surgical career. Role model identification and perceived personality fit were important in selection of all specialties. CONCLUSIONS: Medical students who choose surgical careers are not deterred by a negative perception of lifestyle and workload considerations. Mentoring and personality fit are central in medical student specialty selection.

OBJECTIVE: To develop a system for recording surgical procedure digitally using a personal computer with real-time compression of the video signal. STUDY DESIGN: We built the system around a modern personal computer with a large hard disk to allow recording of over 250h of continuous surgery. Digital capture from the camera was achieved using a standard external analogue-digital converter linked to the computer via a firewire cable. The software for capturing, compressing and editing movie files were obtained free of charge from the internet. The optimal settings for the software was determined. RESULTS: We have successfully used this system to record over 100 major and minor hysteroscopic, laparoscopic, vaginal and open gynaecological. Despite compression, the quality of the movies was judged to be very good and still images excellent. The recordings could be integrated in to standard presentation. Still pictures could be printed to provide hard copies for patients and medical notes, and movies burnt on to CDs or DVDs. CONCLUSIONS: A digital recording system built around a standard personal computer is relatively cheap, versatile and has a huge capacity to record surgical procedures.

INTRODUCTION: We evaluated the effect of the postgraduate medical education level (PGY) of surgery residents on recurrence of inguinal hernia, complications, and operative time. METHODS: Post hoc analysis was performed on prospectively collected data from a multicenter Veterans Affairs (VA) cooperative study. Men were randomly assigned to open or laparoscopic inguinal hernia repairs with mesh. Surgery residents performed repairs with designated attending surgeons present throughout all procedures. PGY level of the resident was recorded for each procedure. All patients were followed for 2 years for hernia recurrence and complications. PGY levels were grouped as follows: group I = PGY 1 and 2; group II = PGY 3; group III = PGY >/= 4; rates of recurrence, complications and mean operative time were compared. RESULTS: A total of 1983 patients underwent hernia repair. group III residents had significantly lower recurrence rates for open repairs when compared with group I (adjusted odds ratio = 0.24, 95% confidence interval [CI], 0.06, 0.997). The recurrence rate was similar among the groups for laparoscopic repair (P > 0.05) Complication rates were not different for either repair (P > 0.05). Mean operative time was significantly shorter for group III compared with group I for both open (-6.6 minutes; 95% CI, -11.7, -1.5) and laparoscopic repairs (-12.9 minutes; 95% CI, -19.8, -6.0) and between group II and group I for laparoscopic repair (-15.0; 95% CI, -24.3, -5.7). CONCLUSIONS: Despite the presence of an attending surgeon, open hernia repairs performed by junior residents were associated with higher recurrence rates than those repaired by senior residents. Lower resident level was associated with increased operative time for both open and laparoscopic repair.

Although some separation of surgery from the practice of medicine had begun to develop in early medieval times, this was accentuated in 1215 by the Fourth Lateran Council, a papal edict which forbade physicians (most of whom where clergy) from performing surgical procedures, as contact with blood or body fluids was viewed as contaminating to men of the church. As a result, the practice of surgery was relegated to craft status with training by apprenticeship through guilds. Physicians followed a university-directed program of education, which involved knowledge of the classics and writings of ancient medical authors such as those by Galen, which allowed no independent thought or inquiry. Competition among physicians and surgeons, including the lowest group of surgical practitioners, the barbers, continued until Henry VIII signed a charter in 1540 uniting barbers and surgeons in London. This Guild of Barbers and Surgeons, forerunner of the Royal College of Surgeons, established a regulatory agency for training and certification of surgical practice, which set the stage for legitimizing surgery as a profession.

Surrogate end points in clinical research pose real danger. A surrogate end point is an outcome measure, commonly a laboratory test, that substitutes for a clinical event of true importance. Resistance to activated protein C, for example, has been used as a surrogate for venous thrombosis in women using oral contraceptives. Other examples of inappropriate surrogate end points in contraception include the postcoital test instead of pregnancy to evaluate new spermicides, breakage and slippage instead of pregnancy to evaluate condoms, and bone mineral density instead of fracture to assess the safety of depo-medroxyprogesterone acetate. None of these markers captures the effect of the treatment on the true outcome. A valid surrogate end point must both correlate with and accurately predict the outcome of interest. Although many surrogate markers correlate with an outcome, few have been shown to capture the effect of a treatment (for example, oral contraceptives) on the outcome (venous thrombosis). As a result, thousands of useless and misleading reports on surrogate end points litter the medical literature. New drugs have been shown to benefit a surrogate marker, but, paradoxically, triple the risk of death. Thousands of patients have died needlessly because of reliance on invalid surrogate markers. Researchers should avoid surrogate end points unless they have been validated; that requires at least one well done trial using both the surrogate and true outcome. The clinical maxim that "a difference to be a difference must make a difference" applies to research as well. Clinical research should focus on outcomes that matter.

The effect of a treatment versus controls may be expressed in relative or absolute terms. For rational decision-making, absolute measures are more meaningful. The number needed to treat, the reciprocal of the absolute risk reduction, is a powerful estimate of the effect of a treatment. It is particularly useful because it takes into account the underlying risk (what would happen without the intervention?). The number needed to treat tells us not only whether a treatment works but how well it works. Thus, it informs health care professionals about the effort needed to achieve a particular outcome. A number needed to treat should be accompanied by information about the experimental intervention, the control intervention against which the experimental intervention has been tested, the length of the observation period, the underlying risk of the study population, and an exact definition of the endpoint. A 95% confidence interval around the point estimate should be calculated. An isolated number needed to treat is rarely appropriate to summarize the usefulness of an intervention; multiple numbers needed to treat for benefit and harm are more helpful. Absolute risk reduction and number needed to treat should become standard summary estimates in randomized controlled trials.

The overwhelming increase in the quantity of clinical evidence has led to detachment of the evidence and practice because new evidence can be integrated into clinical practice only after it has been critically appraised and synthesized on the basis of the existing evidence. Because many clinicians lack the skills and the time for such information processing, systematic reviews and meta-analyses, their quantitative counterparts, play an important role in health care. Well performed systematic reviews provide clinically relevant information for surgeons, abrogating the need to identify, read, and evaluate many individual studies. This article reviews the basic principles of meta-analysis, discusses its potential weaknesses such as heterogeneity and publication bias, and highlights special situations when dealing with surgical trials.

There are now five classic steps for analysis of diagnostic and therapeutic medical decision-making policies: (1) formulate a clear clinical question based on a particular patient's problem; (2) search the literature for relevant clinical articles; (3) evaluate the evidence for its validity and usefulness; (4) implement useful findings into clinical practice; (5) audit the validity of the process. The clinician must have the necessary skills to appraise critically the information retrieved. Rather than focusing on the discussion and conclusion sections of articles, the reader should concentrate on the review of the methods and results sections to formulate an opinion regarding the strength of evidence presented in the paper. The process is intellectually demanding and difficult to achieve. This particular step in the validation of evidence implies that each clinician must be methodologically and statistically sound, an "expert," capable of analyzing the method used in that particular publication to achieve the published result.

The objectives of teaching evidence-based surgery (EBS) are to inform and convince that EBS is a method of interrogation, reasoning, appraisal, and application of information to guide physicians in their decisions to best treat their patients. Asking the right, answerable questions, translating them into effective searches for the best evidence, critically appraising evidence for its validity and importance, and then integrating EBS with their patients' values and preferences are daily chores for all surgeons. Teaching and learning EBS should be patient-centered, learner-centered, and active and interactive. The teacher should be a model for students to become an expert clinician who is able to match and take advantage of the clinical setting and circumstances to ask and to answer appropriate questions. The process is multistaged.Teaching EBS in small groups is ideal. However, it is time-consuming for the faculty and must be clearly and formally structured. As well, evidence-based medicine (EBM) courses must cater to local institutional needs, must receive broad support from the instructors and the providers of information (librarians and computer science faculty), use proven methodologies, and avoid scheduling conflicts. In agreement with others, we believe that the ideal moment to introduce the concepts of EBM into the curriculum of the medical student is early, during the first years of medical school. Afterward, it should be continued every year. When this is not the case, as in many countries, it becomes the province of the surgeon in teaching hospitals, whether they are at the university, are university-affiliated, or not, to fulfill this role.

The limitations associated with the traditional randomized controlled design as applied to clinical surgical research must be recognized. The aim of randomization is to ensure initial comparability between groups of eligible patients for whom treatments are compared, thus eliminating their individual influence on outcome. Randomized controlled trials in the surgical literature are sparse; patient preferences might be a major obstacle to their performance. External validity of results of clinical trials depends on the representativity of patients who participate in trials: Compliance to participate through informed consent may act as a selection bias. In surgical randomized trials where it is not often possible for patients to remain blinded to the treatment to which they have been allocated, patient preferences can influence the effectiveness of treatments. In this setting, we need to look at alternatives and the potential advantages of adopting more flexible and clinically relevant approaches to the design of surgical trials. We have to accept the weight of the patient's individual decision in everyday practice. Hence, to negate the importance of these individual choices when evaluating surgical outcomes is unrealistic. An original design reported herein might become a new paradigm for surgical evaluation.

Limits of Evidence-based Surgery. Slim K
World J Surg 2005 Apr 14;

Evidence-based medicine can be summarized as the use of current best evidence in the care of individual patients. When applied to surgical practice, it appears clearly that the concept of evidence-based medicine involves some limitations. To discuss these limits, the author went back over the terms of the evidence-based medicine definition. Limits are related to the low quantity and quality of randomized controlled trials and meta-analyses in surgery, the difficulties when critically appraising the literature and applying the results of evidence to individual patients, and bringing surgeons more willing to endorse the principles of evidence-based medicine. However all these limits can be overcome in the future, with the aim that evidence-based surgery will not be a passing fad.

History and Development of Evidence-based Medicine. Claridge JA, Fabian TC
World J Surg 2005 Apr 14;.

This article illustrates the timeline of the development of evidence-based medicine (EBM). The term "evidence-based medicine" is relatively new. In fact, as far as we can tell, investigators from McMaster's University began using the term during the 1990s. EBM was defined as "a systemic approach to analyze published research as the basis of clinical decision making." Then in 1996, the term was more formally defined by Sacket et al., who stated that EBM was "the conscientious and judicious use of current best evidence from clinical care research in the management of individual patients." Ancient era EBM consists of ancient historical or anecdotal accounts of what may be loosely termed EBM. This was followed by the development of the renaissance era of EBM, which began roughly during the seventeenth century. During this era personal journals were kept and textbooks began to become more prominent. This was followed by the 1900s, during an era we term the transitional era of EBM (1900-1970s). Knowledge during this era could be shared more easily in textbooks and eventually peer-reviewed journals. Finally, during the 1970s we enter the modern era of EBM. Technology has had a large role in the advancement of EBM. Computers and database software have allowed compilation of large amounts of data. The Index Medicus has become a medical dinosaur of the past that students of today likely do not recognize. The Internet has also allowed incredible access to masses of data and information. However, we must be careful with an overabundance of "unfiltered" data. As history, as clearly shown us, evidence and data do not immediately translate into evidence based practice.

Why We Need Confidence Intervals.Altman DG
World J Surg 2005 Apr 14;

The estimation approach to statistical analysis aims to quantify the effect of interest as an "estimate" of a clinically relevant quantity and to quantify the uncertainty in this estimate by means of a confidence interval (CI). As such, results expressed in this form are much more informative than results presented just as p values. This article focuses on the principles rather than the mathematics of CIs and discusses interpretation of CIs and some common misuses. CIs can be constructed for almost all analyses. They are especially useful for avoiding misinterpretation of nonsignificant results of small studies. CIs should be provided routinely for the main results of trials and observational studies.

How To Analyze an Article.Urschel JD
World J Surg 2005 Apr 21;.

n clinical research investigators generalize from study samples to populations, and in evidence-based medicine practitioners apply population-level evidence to individual patients. The validity of these processes is assessed through critical appraisal of published articles. Critical appraisal is therefore a core component of evidence-based medicine (EBM). The purpose of critical appraisal is not one of criticizing for criticism's sake. Instead, it is an exercise in assigning a value to an article. A checklist approach to article appraisal is outlined, and common pitfalls of analysis are highlighted. Relevant questions are posed for each section of an article (introduction, methods, results, discussion). The approach is applicable to most clinical surgical research articles, even those of a nonrandomized nature. Issues specific to evidence-based surgical practice, in contrast to evidence-based medicine, are introduced.

Clinicians frequently confront challenges when using diagnostic tests to help them decide whether the patient before them suffers from a particular target condition or diagnosis. The primary issues to consider when determining the validity of a diagnostic test study are how the authors assembled the patients and whether they used an appropriate reference standard in all patients to determine whether the patients did or did not have the target condition. Surgeons should be interested in the characteristics of the test that indicates the direction and magnitude of change in the probability of the target condition associated with a particular test result. The likelihood ratio best captures the link between the pretest probability of the target condition and the probability after the test results are obtained (also called the posttest probability). Many studies, however, present the properties of diagnostic tests in less clinically useful terms: sensitivity and specificity. Sensitivity denotes the proportion of people with the disorder in whom the test result is positive. Specificity denotes the proportion of people without the disorder in whom the test result is negative. Application of the guides presented in this article can allow surgeons to assess critically studies regarding a diagnostic test.

BJECTIVES: This paper must fulfill three different tasks: First, to introduce the topic "Electronic Patient Information -- Pioneers and MuchMore", second, to introduce the invited authors of the symposium, and third, to serve as the author's academic farewell lecture as professor emeritus. RESULTS: The electronic patient record, with all its different kinds of patient information, can be structured in many ways. Here, an historical approach is presented with a primary focus on the development of an information system for in- and outpatients in Germany, especially in Frankfurt, but also in comparison with US systems. The "Stone Age" and "Bronze Age" of patient-related computer applications started with expensive and insufficient hardware, but some years later, the first systems for patient documentation, text generation, and data acquisition could be implemented. The "iron age" and "golden age" yielded until the mid-1970s, e.g. in Oakland, Boston, Salt Lake City, and Frankfurt, quite successful Hospital Information Systems with some special emphasis on natural language processing. The following dark years were filled primarily with administrative systems, but beginning in the early 1980s, an era of enlightenment started, e.g. with rather inexpensive and easy to use PC application, broadly distributed MUMPS systems, and improved thesaurus-based text analysis. Especially in modern times, the medical text processing and classifying has been extended and successfully applied. CONCLUSIONS: Somewhat in contrast to other approaches, in the future the use of medical linguistics for the development of a successful electronic patient record should be better supported. Electronic patient information should be available wherever and whenever needed. For this, intelligent and automated reporting and controlled data exchange is necessary. The computer should do all classification, coding, and administrative work, and the physician should get all relevant information necessary for decision making.

Selected impressions on the beginning of the electronic medical record and patient information. Klar R
Methods Inf Med 2004;43(5):537-42.

OBJECTIVES: To present an overview of early European and American work on Electronic Medical Records and patient information. METHOD: The invited lectures of "pioneers of electronic patient information" given at the farewell symposium of Wolfgang Giere in Frankfurt, Germany, are summarized and discussed. RESULTS: The origin of medical record writing goes back to Hippocrates and over many centuries this important medical duty was regarded as an annoying, laborious and error-prone task. First steps towards a better medical record started in 1936 with punch cards. In the 1960s the minimum basic data set, a unique patient ID was introduced and even for outpatients first computerized medical record systems were developed applying some important standards and well accepted data structures. Nowadays multimedia are included in patient record systems, highly specialized subsystems e.g. for radiology or cardiology are available, and semantic and statistic mining techniques as well as medical classifications and standardized terminologies support evaluation. All these methods should primarily improve the quality of care, reduce errors, improve communication between multiple specialists, reduce wait times for patients and improve efficiency. CONCLUSIONS: Over decades it became obvious that the structure of a medical record notably for coded data but also for narrative text and pictures must be carefully modelled. Well maintained standardized health terminologies and medical classifications are important issues for a user-friendly electronic medical record, which bring benefits for clinicians and patients.

OBJECTIVE: Medical knowledge management and care process management have become to be considered as valuable strategic assets that can lead to sustained increase in Health Care Organization (HCO) performance. Thus, it is essential to investigate which are the enablers for promoting knowledge-based organizations (people, organization, process, and system perspectives). Although they are essential for a HCO to manage knowledge effectively, it is still unclear how to employ them in more principled fashion. This requires innovative management strategies to determine effective ways of utilizing knowledge resources and capabilities available both within and outside the organization. METHOD: This paper reviews knowledge and process management theories, methods, and technologies that are potentially effective in building high performance HCOs. They come from a variety of fields behind computer science and medical informatics, e.g. from business and organization sciences to psychological and cognitive sciences, from epistemology to sociology. However, the success in developing future Health Information Systems (HIS) requires their incorporation into a new conceptual framework after recognizing how peculiar are the characteristics of HCOs with respect to other organizations. Investigating the nature of knowledge, in general, and of medical knowledge, in particular, is essential to define which services the future HIS should provide to foster collaboration between patients and health professionals. The knowledge creation process is then described in order to emphasize its dynamic and social characteristics. The potential of workflow technology for building innovative HISs is analyzed together with several basic research issues which are very challenging for researchers in the field. RESULT: A framework for augmenting the conceptual analysis of theories, methods, tools and effects of knowledge management in building high performance HCOs.

OBJECTIVES: According to results from the epidemiological literature, it can be expected that the prevalence odds ratio (POR) and the prevalence ratio (PR) differ with increasing disease prevalence. We illustrate different concepts to calculate these effect measures in cross-sectional studies and discuss their advantages and weaknesses, using actual data from the ISAAC Phase III cross-sectional survey in Munster, Germany. METHODS: We analyzed data on the association between self-reported traffic density and wheeze and asthma by means of the POR, obtained from a logistic regression, and the PR, which was estimated from a log-linear binomial model and from different variants of a Poisson regression. RESULTS: The analysis based on the less frequent disease, i.e. asthma with an overall prevalence of 7.8%, yielded similar results for all estimates. When wheezing with a prevalence of 17.5% was analyzed, the POR produced the highest estimates with the widest confidence intervals. While the point estimates were similar in the log-binomial model and Poisson regression, the latter showed wider confidence intervals. When we calculated the Poisson regression with robust variances, confidence intervals narrowed. CONCLUSIONS: Since cross-sectional studies often deal with frequent diseases, we encourage analyzing cross-sectional data based on log-linear binomial models, which is the 'natural method' for estimating prevalence ratios. If algorithms fail to converge, a useful alternative is to define appropriate starting values or, if models still do not converge, to calculate a Poisson regression with robust estimates to control for overestimation of errors in the binomial data.

Evidence-based medicine is the conscientious, explicit and judicious use of the current best evidence in making decisions about the care of individual patients. Along with individual clinical expertise, it is a required core skill for clinical problem solving and it is considered to be a comprehensive component of the medical curricula. This chapter is a general overview of the steps to be followed by clinicians to search, identify and appraise the best-available evidence that could help them to resolve a particular clinical problem. It includes the principles for the identification of a clinical problem and its translation into a question, and the main sources for searching and locating the best-available evidence. References for guidelines designed for appraisal of the methods used in the original papers and for the interpretation of its results are also provided.

This study aimed to evaluate the exposure of obstetrics and gynecology residents to urogynecologic training and to compare this to the program directors' expectations. A cross-sectional questionnaire study was performed surveying the 60 final-year residents and their program directors at all 16 Canadian residency programs. Questions covered areas of knowledge and skills in basic and advanced urogynecology. Thirty-two (53%) residents and nine (56%) program directors responded. Twenty-six (81%) residents had a formal urogynecology rotation with training in incontinence, prolapse, pessary-fitting, and urodynamics. Residents performed a median of: 50 vaginal hysterectomies, 30 anterior repairs, 30 posterior repairs, 35 retropubic urethropexies, and 15 cystoscopies. All other procedures had a median of 6 or less. Responses of residents and program directors correlated well. Although residents in Canada have adequate exposure to simple urogynecologic procedures, they perform few complex cases. Such procedures should be performed by physicians with additional urogynecology fellowship training.

The past 2 decades have witnessed a surge of interest and investment in transdisciplinary research teams and centers. Only recently, however, have efforts been made to evaluate the collaborative processes and scientific and public policy outcomes of these endeavors. This paper offers a conceptual framework for understanding and evaluating transdisciplinary research, and describes a large-scale national initiative, the National Institutes of Health Transdisciplinary Tobacco Use Research Centers (TTURCs) program, undertaken to promote cross-disciplinary scientific collaboration in the field of tobacco use science and prevention. A 5-year evaluation of collaborative processes and outcomes observed across multiple TTURC centers conducted during 1999 to 2004 is described. The findings highlight key contextual circumstances faced by participating centers (i.e., the breadth of disciplines and departments represented by each center, the extent to which members had worked together on prior projects, spatial proximity among researchers' offices, and frequency of their face-to-face interaction) that influenced their readiness for collaboration and prompted them to follow different pathways toward transdisciplinary integration. Implications of these findings for developing and evaluating future transdisciplinary research initiatives in the field of active living research are discussed.